Name of the Procedure:

Skilled Services of a Registered Nurse (RN) for Observation and Assessment of Patient's Condition, Each 15 Minutes (G0493)

• Common Names: RN Observation, Skilled Nursing Assessment
• Technical/Medical Term: Skilled Nursing Services for Patient Monitoring

Summary

This procedure involves a registered nurse (RN) providing skilled observation and assessment of a patient's condition every 15 minutes. The RN's expertise is required to identify and evaluate changes in the patient's condition that may necessitate further medical intervention.

Purpose

• Medical Conditions Addressed: Changes in patient condition requiring skilled nursing evaluation, such as post-surgery recovery, chronic illness management, acute illness observation.
• Goals/Expected Outcomes: Early identification of complications, timely initiation of appropriate medical interventions, improved patient outcomes.

Indications

• Symptoms/Conditions: Unstable vital signs, post-operative patients, patients with acute or chronic conditions requiring close monitoring.
• Patient Criteria: Individuals with fluctuating health status, those requiring critical observation, or patients whose condition may necessitate rapid medical response.

Preparation

• Pre-Procedure Instructions: No specific patient preparation required. Patients should continue their current medications unless otherwise instructed by their healthcare provider.
• Diagnostic Tests/Assessments: Relevant medical history review and any necessary baseline diagnostic tests to understand the patient's current condition.

Procedure Description

1. Initial Assessment: The RN conducts a thorough initial assessment, including checking vital signs, reviewing patient history, and noting any immediate concerns.
2. Ongoing Observation: Every 15 minutes, the RN reassesses the patient, paying close attention to any changes in vital signs, symptoms, or overall condition.
3. Documentation: The RN meticulously documents each observation and assessment, noting any changes and their potential significance.
4. Interventions: If any changes are detected, the RN determines the necessary interventions or adjustments to the patient's care plan.
   • Tools/Equipment: Stethoscope, blood pressure monitor, pulse oximeter, thermometers, electronic health records system.
   • Anesthesia/Sedation: Not applicable.

Duration

• Each observation and assessment period is conducted in 15-minute intervals, with the total duration depending on the patient's condition and healthcare needs.

Setting

• Typically performed in hospitals, outpatient clinics, or home healthcare settings.

Personnel

• Primarily conducted by a Registered Nurse (RN).
• May involve collaboration with other healthcare providers such as physicians, nurse practitioners, and specialists.

Risks and Complications

• Common Risks: Minimal, primarily related to the invasive nature of certain assessments (e.g., discomfort during blood pressure measurement).
• Rare Risks: Failure to detect a rapid change in condition, leading to delayed intervention.
• Management of complications involves prompt communication with the healthcare team and appropriate medical response.

Benefits

• Expected Benefits: Early detection of complications, timely intervention, stabilization of patient’s condition, improved quality of care.
• Realization Timeline: Benefits can be immediate with continuous monitoring.

Recovery

• Post-Procedure Care: Ongoing observation as needed based on the patient's condition.
• Recovery Time: Not applicable as it is a monitoring procedure.
• Restrictions/Follow-Up: Follow-up care is dependent on the findings from the RN's assessments.

Alternatives

• Other Treatment Options: Less frequent monitoring, use of automated monitoring systems.
• Pros and Cons: Continuous RN monitoring provides a personalized and immediate response that automated systems or less frequent checks may not offer. However, automated systems may reduce costs and required personnel resources.

Patient Experience

• During Procedure: Patients can expect regular check-ins from the RN every 15 minutes, which may include measurement of vital signs and brief discussions about their condition.
• Post-Procedure: Continual monitoring as needed, with emphasis on comfort and regular reassessment to ensure patient well-being.
• Pain Management/Comfort Measures: The process is generally non-invasive and designed to ensure patient comfort and safety.